Orthotics Contact Info. | Orthotics Links

Scoliosis usually is not noticeable until the curve is 20 degrees. Therefore, following a "small curve" is not recommended because bracing is usually started at 25 degrees. Early referral to an experienced scoliosis physician is warranted to provide early treatment.

Scoliosis is a lateral curvature of the spine with rotation of the vertebrae about the vertical axis. Adolescent idiopathic scoliosis which accounts for 80 to 85 percent of all cases of scoliosis typically occurs at or near the onset of puberty.

The cause of adolescent idiopathic scoliosis remains unknown, and whether it is caused by abnormal balance or abnormalities in the labyrinthine or ocular systems continues to be debated. Neuromuscular scoliosis usually can be determined by a careful history and physical and congenital scoliosis can be diagnosed by radiographs. With 10 degrees as the minimal level of curvature required to make the diagnosis of adolescent idiopathic scoliosis, the prevalence of this condition in the at risk population (children 10 to 16 years of age) is approximately 2 to 3 percent. Most curves spontaneously stabilize and this is substantiated by a decreased prevalence of larger curves.

There are several factors that correlate with an increased risk of curve progression. They are sex, curve pattern, physiologic age of the child, and curve magnitude. Females have a much greater risk for progression than males of similar ages with curves of similar magnitude. Overall, females predominate 3.6 to 1 compared to males. When the curve reaches 30 degrees or more, females predominate by a 10:1 ratio over males. Thoracic and double major curve patterns are at greater risk for curve progression than thoracolumbar or lumbar curves. The curves of skeletally immature children are more likely to progress than those children who are nearing the skeletal maturity. The absence of menarche at presentation is an important risk factor for progression of the curve. Because skeletal maturity of the male spine occurs later, male spines seem to show more curve progression later in adolescence (between ages 16 and 19) compared with females and require closer observation.

There are many reasons why scoliosis may be undetected until a substantial deformity has developed. These include:

1. Nearly all cases are painless and produce no other symptoms.
2. Idiopathic scoliosis most often develops in the preadolescent or early adolescent period, an age of modesty which precludes parents from seeing their child's unclothed spines.
3. Routine physical examination of older children has been supplanted by episodic problem-related health care.
4. Currently popular loose clothing styles easily conceal significant deformity.

Most cases of idiopathic scoliosis do not reach severe magnitude but those that do can have significant sequela. These include:

1. Restrictive pulmonary disease which can lead to corpulmonale and premature death. 2. Back pain, particularly in the lumbar and lumbosacral regions. 3. Increased fatigueability. 4. Objectionable cosmetic deformity. 5. Psychogenic problems with body image. 6. Social problems such as increased unemployment and decreased likelihood of marriage. 7. The expense of further medical care later in life.

Because scoliosis can be difficult to detect, many states have mandated that screening school children for scoliosis is an appropriate way to improve early detection and prevent progression through substantial deformity and its consequences. The screening test for scoliosis is a rapid, accurate, and low-cost means of identifying nearly all cases of scoliosis. It has a low false positive and false negative rate and the spontaneous detection rate without such screening is too low.

The natural history of idiopathic scoliosis is well understood and favorably altered by early treatment so that undesirable consequences are avoided. The screening examination for idiopathic scoliosis takes about one minute. Boys should be dressed from the waist up and girls can wear a bathing suit or bra which will not interfere with the examination and will provide them with some measure of modesty. The student stands straight but relaxed with the back facing the examiner. The student's feet are together, and head up and looking straight ahead with the arms hanging relaxed at the sides.

The examiner should look for asymmetrical shoulder heights, scapular prominences, unequal distances from the arms to the flanks, unequal waistline or high hip, deviation of the head and neck from over the intergluteal cleft, pelvic obliquity, and lower limb length inequality. Next, and most important, is the forward bending or Adams test. With the feet together and knees straight, the child bends the hips to nearly 90 degrees with the arms dangling forward. Viewed from behind and in front, both sides of the chest and both sides of the lumbar area should be symmetrical.

The most consistent early sign of scoliosis is an asymmetrical prominence on one side of the thoracic or lumbar area. An obvious curve or lateral deviation of the spinous processes is also seen in this position. Kyphosis or roundback may be seen best from the side as the student bends forward. The forward bending test completes the screening examination.

Many humans are slightly asymmetrical so it requires some clinical judgment to identify those patients who require further follow-up. The use of an inclinometer such as the Bunnell Scoliometer is a useful and inexpensive way of documenting trunk rotation. We recommend referring cases for examination if the angle of trunk rotation is 7 degrees or more.

The most common curve patterns in idiopathic adolescent scoliosis are (in decreasing frequency), thoracic, double major, thoracolumbar, double thoracic, and lumbar. The thoracic pattern is the most physically deforming and most notable type of scoliosis. A double major curve on the other hand can have less cosmetic deformity despite a large magnitude of curvature. Thoracolumbar curves typically cause an asymmetric waist crease. Double thoracic curves often present as unequal shoulders caused by the high left thoracic curve. Finally, lumbar curves present with an asymmetric waistline and unequal arm-to flank distances.

The Management of Adolescent Scoliosis

A careful neurologic examination should be performed in every child who has scoliosis. The term "scoliosis" is a physical sign and not a codable diagnosis so other causes such as neuromuscular disease or congenital anomalies of the spine must be ruled out. The physician should also obtain a standing posterior/anterior radiograph of the entire thoracolumbar spine. A baseline radiograph is necessary in almost all cases of scoliosis because one cannot differentiate idiopathic from congenital scoliosis by clinical examination alone. Congenital scoliosis has a much different prognosis and is associated with renal, heart, and intraspinal anomalies that may be important to detect early.

Radiographs remain the standard for documentation of scoliosis. Topographical methods for evaluating trunk rotation such as the inclinometer, the Moiré Fringe Evaluation and the ISIS system have not been proven to be accurate or definitive indicators of scoliosis. In growing children, curves of less than 25 degrees can be safely followed since many will not worsen or require treatment. However, curves in the magnitude of 25 to 30 degrees or greater, often require active treatment at the time of diagnosis. It is suggested that growing children with curves of less than 10 degrees be followed annually. They often do not need x-rays at every outpatient visit. Many experienced physicians follow mild scoliosis by physical examination only. Curves in the 10- to 30-degree range should be seen every 6 months and curves in the 20- to 30-degree range should be seen every 4 months through-out the growth period.

Other than periodic observation and documentation, the only two effective methods of managing scoliosis are orthotic treatment and surgery. Other "treatment" techniques including electrical stimulation of muscles, manipulation of the spine, exercises, and diet have never been shown to affect the natural history of scoliosis in any way. Occasionally, patients are seen whose curves have no doubt worsened substantially while ineffective treatments have been applied.

A growing child with a curve in the range of 25 to 30 degrees up to 40 degrees should be treated with an appropriate orthosis. Most physicians use low profile, custom fabricated, thoracolumbosacral orthosis (TLSO). The traditional treatment protocol prescribes 23 hours of brace wear but some curves are appropriate for part-time orthosis wear (8 to 12 hours per night). The orthosis is worn until the patient shows signs of skeletal maturity, including cessation of growth and height, the attainment of radiographic Risser Stage IV (full capping of the iliac apophysis), and greater than 18 months post-menarche in females. Radiographs of the hand and wrist may be compared to a standard atlas to further confirm skeletal maturity.

It is very important for the patient, the parents, and the physician, to realize that the goal of orthotic treatment of idiopathic scoliosis is simply to halt curve progression. Most curves will appear substantially improved while the orthosis is worn; however, the great majority will settle back to their original pre-treatment magnitude within two years of brace discontinuance.

The effectiveness of brace treatment is difficult to assess but, based on the most recent data for curves between 20 and 29 degrees, brace failures occurred in 30 percent of Risser 0 to 1 patients, contrasted with an expected 68 percent risk of progression. In most studies, about 70 percent of patients have successful arrest of curve progression with orthotic treatment. An estimated 30 percent of these patients would have had their curve progression spontaneously arrested at some point without treatment. Nevertheless, it is impossible to identify such patients by any means other than nonintervention. Orthotic treatment, then, is based on the premise that although 30 percent of compliant patients will fail to have their curves arrested, 70 percent would have had continued progression without treatment.

Curves of greater than 45 degrees in skeletally immature patients are likely to worsen despite orthotic treatment and should be considered for surgical correction and stabilization. The surgery for scoliosis is a comparatively safe and very effective method of preventing the severe morbidity from untreated idiopathic scoliosis. Connecticut Children's Medical Center uses the most current techniques to obtain the safest and most secure surgical stabilization of the spine. These techniques use a double rod system with multiple sites of attachment to the posterior bony elements of the spine either by means of screws, hooks or wires. This allows for the simultaneous application of the corrective forces of distraction, compression, and derotation, and provides rigid internal fixation for maintenance of the correction while the spinal fusion mass is maturing.

SCOLIOSIS IN ADULTS
Scoliosis is not always static once growth ceases. Some curves progress, especially thoracic curves greater than 60 degrees, and they need to be closely watched. Lumbar curves over 50 degrees tend to progress and the likelihood of back pain is higher. Scoliosis can cause significant back pain, cosmetic deformity, and psychological and emotional problems. Once a thoracic curve reaches 90 degrees or more, it is likely that restrictive lung disease will produce corpulmonale and premature death. For these reasons, it is recommended that adults with scoliosis in the 50- to 60-degree range have periodic follow-up at intervals of 1 to 5 years. Braces are not effective to halt scoliosis in adults. Surgery is indicated for those curves which are greater than 60 degrees, have intractable pain, or show documented progression. There is no real upper age limit for successful surgical treatment and patients in their later decades have gained significant cosmetic improvement and relief of back pain by surgical stabilization of their spinal deformity.

Contact:

Department of Orthopaedics
Bruce Bowman, MHS, PA-C
Phone: 860.545.8656
bbowman@ccmckids.org

Deb Lee, RN
Phone: 860.545.9085

For questions related to bracing issues please contact:
Megan Chamis, CO
Phone: 860.545.9050
Hanger Prosthetics and Orthotics
Office Hours: 8:30 a.m. - 5:00 p.m., Tuesdays & Fridays

Links:

The following is a list of Scoliosis web sites that we feel are helpful and scientifically sound. There is a lot more information about idiopathic scoliosis on the Internet. Some web sites have more accurate information than others. Researching Internet web sites can be informative if it is done selectively. Beware of false information, boisterous advertising claims, and statements that are not backed by scientific evidence. Above all, if you have questions about something you've read on the internet, ask your physician or Megan.

For basic information and links to other good web sites, go to:
National Institute of Arthritis and Musculoskeletal and Skin Diseases

For a scoliosis mailing list and anti-fraud information, go to:
Scoliosis Mailing List

Other great web sites are:
Scoliosis Research Society
American Academy of Orthopedic Surgeons